Introduction and background
Prevalence of MSK conditions
The number of people suffering from musculoskeletal (MSK) issues has escalated dramatically over recent years, with 20.3m¹ people now living with one of the more than 200² known MSK conditions.
There are thought to be multiple reasons for the surging number of cases in the UK. The rise in working from home, increased time spent being sedentary and an ageing population are all possible factors, while the longer waiting times for treatment further exacerbate problems.
It is estimated that almost one in five people (18.6%) have a long-term MSK problem³. In fact, there are now more years lived with MSK disabilities such as neck, lower back pain and arthritis than any other long-term condition⁴.
Impacts on businesses
It’s not just people’s health that’s suffering when it comes to MSK injuries. MSK conditions are having a serious impact on the economy, with 8.9 million working days lost to them in 2019/20 - an increase of almost a third on the previous year⁵.
Latest figures from the Health and Safety Executive⁶ (HSE) show that MSK issues account for 28% of all work-related ill health.
Previous research by Ascenti⁷ revealed that one in two people (49%) were experiencing more physical pain since they started working from home, and recent data from the Office for National Statistics⁸ (ONS) suggests that the number of home workers has risen from 27% to 37% over the last two years.
The lasting impact of Covid-19
As well as the likely impact of working from home on employees’ MSK health, a significant proportion of patients (15.5%) who had the Covid-19 virus or were recovering from Covid-19 have reported MSK issues as a symptom⁹.
And, while the last pandemic lockdown ended on 19th July 2021, studies¹⁰ showed that the measures necessary to keep us safe also reduced physical activity and increased sedentary activity levels. These are known risk factors for MSK injuries when people start to exercise again, and so the impacts of the lockdowns could still be being felt now.
The intolerable pressure on the NHS
The rising number of MSK issues is putting huge pressure on the NHS, which is struggling as a result.
As of January 2022, NHS waiting lists currently stand at 6.1m¹¹, the highest since records began¹² – with more people waiting for MSK treatments than any other form of care¹³ and almost a third of all GP consultations being for MSK conditions¹⁴.
The latest available data was published in April 2019, when there were already 45-day waiting lists for physio treatments¹⁵ and, given the extensive waiting lists now, it is likely that the situation is worse still today.
The government has ring-fenced an extra £1bn to tackle treatment backlogs, however, figures suggest that this is likely to fall significantly short of what is needed¹⁶.
How Private Medical Insurance (PMI) is plugging the gap
Fortunately, businesses are helping to plug the gaps left by the health service, with more than a third of UK SMEs increasing their support for employees’ physical and mental health¹⁷.
Employee demand for Business Health Insurance has increased 11.4%¹⁸ and PMI is increasingly likely to be seen as a key part of the Employee Value Proposition.
In 2019, 29% of individual PMI customers purchased a policy due to concerns about NHS waiting times¹⁹. That number is perhaps likely to rise in the current circumstances, which could increase health inequalities²⁰.
The rise of digital health tools
In recent years there had already been an increase in the use of digital health tools and Covid-19 led to a further acceleration in the adoption of patient-facing technology, with 62% of patients reporting increased use²¹.
When patients experience symptoms that aren’t concerning, the majority (60%) would prefer to communicate with a clinician using technology or the telephone²².
Digital health tools enable individuals to take a preventative approach to managing their health, accessing support at an early stage and avoiding the risk of a niggle developing into a serious injury.
Personalised care and digital health
Personalised care is where people have more choice and control over how their care is planned and delivered. It’s designed to empower patients with the knowledge, skills, and confidence to manage their own health more effectively.
Used correctly, clinically-led digital health tools can support the delivery of key components of personalised care, such as Shared Decision Making (SDM) and Supported Self Management (SSM). The Kings Fund states²³: “Technology can improve access to information to enable better decisions about what will work for an individual and can enable individuals to have more control and knowledge about their health.”
Pre-Covid-19, virtual physiotherapy services represented the minority of support offered by both the private and public physiotherapy sectors. However, the pandemic created a sudden need for digital services to be rolled out more widely across the industry.
Since then, virtual physiotherapy services have flourished and been embraced by patients, with recent research of 27,000 patients by Ascenti²⁴ - published on the Chartered Society of Physiotherapy’s (CSP) Innovations Database²⁵ - demonstrating that they can be just as effective as in-person treatment.
With data²⁶ suggesting that 70% of MSK patients do not engage in prescribed exercise, this report will explore whether a clinician-led digital app that provides 24/7 access to education, support and advice leads to greater engagement, improved efficiencies and, most importantly, effective outcomes.
It is an important exploration since, as Sue Brown, the CEO of the Arthritis and Musculoskeletal Alliance (ARMA), recently stated²⁷: ‘Musculoskeletal health is now more important than ever.’
Background to the study
Introducing Ascenti Reach, the first end-to-end clinically-led ‘Supported Self Management’ app
Reach is a new physio-led, app-based physiotherapy service created and owned by Ascenti, the UK’s leading private physiotherapy company.
Developed over the last four years and now piloted by 12,000 patients, Reach is the first physio app to provide an end-to-end hybrid solution, including digital triage, 24/7 access to online clinician support and the empowerment of self-management tools including videos and educational articles. The app promotes healthy active behaviour and effective self-management, while also offering onward referral into Ascenti virtual consultations or face-to-face appointments at one of Ascenti’s 300 nationwide clinics for patients that would benefit from manual therapy and other in-person treatment.
The technology used by Reach has not been white labelled; it has been purpose-built from scratch by Ascenti’s in-house digital team of highly-skilled developers, UX and UI experts, who have collaborated with Ascenti physiotherapists to ensure a high-quality experience. In addition, Ascenti’s growing physiotherapy team, whether home-based or in-clinic, are all directly employed by the company. This end-to-end ownership ensures far greater control of quality, safety, efficiency and effectiveness.
While many health technology apps are designed to keep people out of care, Ascenti Reach has been built to identify the most appropriate, safe, motivating, and convenient treatment pathway for the individual at that time, with the goal of providing them with the tools they need to effectively manage their health.
How the app works
The app is designed to efficiently move patients through three stages:
1. Clinical triage
Reach uses a robust digital assessment and screening process based on validated questionnaires and patient reported outcome measures. It is informed by The International Federation of Orthopaedic Manipulative Physical Therapists’ (IFOMPT) international framework on screening for red flags and potential serious pathologies²⁸ and by the NHS Serious Pathology Guide for Clinicians in Primary Care²⁹ and has been through a rigorous validation process with the experienced senior team at Ascenti. The assessment takes patients about six to eight minutes to complete, gathering information on their pain and condition and how it is affecting their day-to-day life.
Clinician-devised algorithms then assess this data to identify the most safe and appropriate pathway for each patient. There are three assessment outcomes:
- 1. In cases without any signs of serious pathology, a personal exercise plan is automatically created based on assessment responses.
- 2. In cases where there are some indications of serious pathology, the physiotherapist reviewing the assessment will initiate a conversation with the patient via the Chat function in the app, and use the assessment answers and any follow up information to determine the most appropriate line of care.
- If suitable for supported self-management the physio will manually create an exercise plan through Ascenti Reach.
- If the physio feels the patient should see a clinician, they can be referred into a virtual appointment or in-person appointment at one of Ascenti’s 300 clinics nationwide.
- 3. In cases where 'red flag' symptoms are detected, the patient is advised to seek urgent medical attention.
When the patient receives their personalised exercise programme, created or checked by an Ascenti physio, they then move forward into the rehabilitation phase.
Patients are provided with guided videos and instructions that demonstrate how to complete each exercise on their programme. The app format means they can simply place their smartphone or tablet in front of them and follow an entire exercise programme of video workouts, with a timer or counter indicating how long they should continue for.
At the end of each workout, patients receive a celebration icon and can give feedback on their exercises - helping their Ascenti physio to adjust and progress their exercise plans as required. They’re also able to track their own progress using the app's visual graphs and tools and can set exercise reminders to motivate and help them to stick to their routines.
Patients can use the chat feature whenever they want to communicate with a physiotherapist for support and guidance. Physios check in periodically to ensure that patients in their care are happy with their progress.
The app also contains peer-reviewed educational material to help patients to understand their pain and condition and these are delivered at key points in their journey.
As part of Ascenti’s dedication to providing patients with the safest and most appropriate level of care, Reach has an escalation process where patients requiring additional support are offered a virtual appointment or onward referral to one of Ascenti’s 300 clinics nationwide. This is available at any point in the patient’s journey.
As a world-leading provider of virtual physiotherapy, with an award-winning digital service, Ascenti wanted to explore how Reach, its unique ‘physio-supported self-management’ app could be used to increase patient engagement, grow clinician capacity and, ultimately, deliver effective outcomes.
An observational study of 1,010 patients was conducted using data anonymously collected in the app as part of routine care. The patients involved were referred to Ascenti after experiencing neck, back or knee pain and their treatment journeys were mapped over a 12-week period. They joined the programme using Patient Access (part of EMIS Group), an NHS partnership service that connects patients to effective local health services when they need them online or via a mobile app.
This study was supplemented with an eight-question survey that was completed by 304 respondents within four weeks of discharge.
The study suggests that Ascenti Reach, the ‘physio-supported self-management’ app, delivered effective results in a number of key areas.
It has always been a significant challenge to get MSK patients to conduct prescribed home exercise through traditional methods, with research published in Spine Journal suggesting that up to 70% of patients do not adhere to prescribed home exercise³⁰.
The survey found that nearly half (49%) of the respondents used the app 5+ times per week, while a further 29% used it 3-4 times per week. Spot checks taken directly from the app exercise session tracking data at 4-weeks and 8-weeks suggest that this engagement is maintained over a relatively long period, with 62.9% of patients using it in week 4 and 53.5% using it in week 8.
The Global Rating of Change (GROC) is a validated and well-recognised patient reported outcome measure. In this study it was applied to patients to describe their condition at the end of the treatment compared to when they first started on a scale running from -5 (indicating 'very much worse') and +5 (indicating 'very much improved'). An average improvement of 2.1 was found which is considered a clinically meaningful improvement as it goes above the established minimal clinically important difference (MCID) of the GROC scale of 2.0.
Pain was also measured on an 11-point Numerical Rating Scale (NRS), with scores taken at Initial Assessment (IA), and then at 4 weeks, 8 weeks and at discharge at 12 weeks.
Improvements were seen across the study population, with results showing that those people who used the app for the longest period saw the biggest impacts.
- Of the 406 people that used the app for 4 weeks, there was an improvement from 4.79 at Initial Assessment (IA) to 3.96 at discharge - an improvement of 0.84 NRS points
- Of the 236 that used the app for 8 weeks, there was an improvement from 4.72 at IA to 3.24 at discharge - 1.48 NRS points
- Of the 176 that used the app for 12 weeks, there was an improvement from 4.75 at IA to 3.01 at discharge - an improvement of 1.74 NRS points
Convenient clinical access
The app offers direct 24/7 access to a qualified physiotherapist via a Chat service.
Over the 84-day period, users who completed at least one workout sent an average of 7.3 messages. It is interesting to note that while the total number of messages increased as people spent longer with the app and did more workouts, the ratio of messages per workout dropped significantly - from 1.5 messages per workout for people who had done at least five sessions, to 0.18 messages per workout for people who had done at least 100 sessions. This suggests that people needed less clinician support the more experienced and confident they became, which increases efficiency and is a key principle of personalised care and Supported Self Management.
Challenges such as taking time off from work and fitting in healthcare appointments around childcare responsibilities are known barriers to accessing healthcare services³¹. 39.7% of Chat messages sent by patients to clinicians were posted outside of the traditional office hours of 9am-5pm. This suggests that the intervention could lead to some people accessing healthcare support at an earlier stage, which could reduce the risk of further deterioration.
Regular movement is key to treating and preventing MSK conditions, and is an important part of an overall healthy lifestyle.
The average number of exercise sessions across the 12 weeks (among patients who completed at least one exercise session) was a significant 33 - an average of 2.76 per week. Those users that engaged for the full 12 weeks completed an average of 69 workouts - 5.75 per week.
With Government and NHS guidelines for activity suggesting that adults should spread exercise evenly over 4-5 days each week³², or every day, and do strengthening activities that work all the major muscle groups, these results suggest that Ascenti Reach can make a significant contribution towards people meeting those targets.
Patient satisfaction with the app was high across the board, particularly considering that the study was conducted while the service was still in the pilot stage.
On a scale of 0-4, where 0 is very satisfied and 4 is very dissatisfied, users scored 0.9 - between very satisfied and satisfied.
Patient satisfaction appeared to increase the longer they engaged with the app, rising from 87.2% at 4 weeks, to 91.5% at 8 weeks, to 93.6% at 12 weeks.
In terms of features, when surveyed patients reported feeling satisfied with how easy to use the app was (97.5%), the quality of the videos (98.9%), the quality of the advice and guidance content (91.4%), the quality of the physio support in the Chat function (89.0%), the speed of this support (86.8%) and the progress tracking feature (88.9%). The slightly lower satisfaction scores for Chat support and progress tracking have been identified as areas for improvement and highlighted the expectations patients have of these features.
86.2% of patients that used Ascenti Reach say they would actively recommend it to friends and family.
While a physiotherapist providing in-person treatment might have the capacity to see around 40-50 patients each week, an Ascenti Reach physiotherapist can fulfil a much higher Active Capacity and therefore support more people to manage their own MSK health effectively.
In addition, the evidence suggests that people require less direct clinical contact the longer they engage with the app, which further increases efficiency. Coming at a time when NHS waiting lists for MSK injuries are at record levels, this service could help meet an important societal need in a cost-effective way.
During the course of the pilot a number of patients were identified as having a potentially more serious or specific pathological condition and they were appropriately recommended to face-to-face physiotherapy or to see their GP, demonstrating that this system is effective. It does not appear that there were any errors in the study, for example where a patient with more serious pathology such as a fracture, CES or cancer was not picked up in the screening process, and no safety incidents were reported.
The study is based on patients accessing physiotherapy treatment for a range of needs and so the results must be interpreted as general findings and it should not be assumed that they apply equally to all injury types - for example those involved in Road Traffic Accidents.
In addition, while the data captured demonstrated clinically meaningful results and positive scores in a range of areas, there may be benefit to designing future research to include a control group so more direct comparisons with in-person treatment can be made.
Against a backdrop of record NHS waiting lists, surging adoption of digital health tools and a cultural move towards a more empowering personalised care health system that equips people to manage their own health more effectively, it is the right time to explore the concept of end-to-end clinically-led ‘physio-supported self-management’. An exploration of the potential advantages and disadvantages is below.
- Convenient - patients have full control of their treatment journey. They can access activity sessions and clinical support at a time that suits them. This increases the chances of them seeking out support at an earlier stage, since they don’t need to organise time off work, engage childcare support or make travel arrangements. Early interventions can enable faster recovery and prevent further deterioration.
- Empowering - receiving manual therapy can be quite passive and patients often attend appointments with the intention of ‘being treated’. With physio-supported self-management delivered through an app like Ascenti Reach, the onus is on the patient to take control of their own rehabilitation. It encourages accountability and digital tools like progress trackers and celebration icons can be very motivating. Self-management is consistently recommended across guidelines for painful MSK conditions and this app makes that process easier³³.
- Reassuring – digital health tools like Reach that enable regular clinical contact can be very reassuring for patients who may wish to check in that they are on the right track. Traditional in-person physio may inadvertently encourage patients to ‘save up’ questions for their next appointment and people may worry about whether they are doing exercises correctly. Direct 24/7 clinical access and digital tools such as exercise demonstration videos enable people to check in earlier and more frequently, potentially reducing any concerns.
- Appropriate referrals – digital triage based on validated questionnaires ensures patients are directed towards services that best meet their need, reducing the strain that inappropriate referrals can place on already stretched healthcare services. It reduces time wasted by clinicians and patients and increases cost-effectiveness and efficiency.
- New types of career - the emergence of innovative digital health tools like Ascenti Reach opens the door for new types of interesting careers for physiotherapists. Physiotherapists now have the opportunity to have flexible roles that combine digital innovation with in-person treatment, allowing them to help more people overall. They can be in-clinic one day and working from home the next, combining the development of digital support plans with providing advice and manual therapy.
- Cost effectiveness. Introducing an innovative service line, for the right people and the right time - optimising referrals and creating more efficient care pathways.
- Digital inclusion - although we have seen an unparalleled surge in digital health adoption, a significant proportion of people don't have access to digital devices and some do not feel confident using digital tools. It is very important that digital health tools are offered only as part of a broader healthcare eco-system that also includes in-person treatment. This ensures that the right people get access to the right support at the right time. Ascenti’s end-to-end service gives people choice, which includes supporting people who struggle with digital access by offering appointments at one of its 300 nationwide clinics.
- Reduced trust - while digital triage has been found to be effective, some patients may be more likely to trust a diagnosis that is given to them after a physical examination. This could be because they worry about their interpretation of certain questions and whether they are responding appropriately. It is vital that digital assessment and screening surveys are rigorous in their methodology. Clinician reviews, escalation procedures and regular clinician messaging can help alleviate any risk of error.
- Response times and patient expectations - throughout the course of the study period, in order to better understand patient expectations and help optimise the service, Ascenti experimented with higher and lower caseloads for its Reach clinicians. As with any customer response service, there were busier and less busy times when it came to managing patient queries. Striking the right balance to ensure that there is enough capacity for clinicians to respond within an acceptable time period will help to ensure patients remain satisfied with the service and benefit from timely advice and support.
With MSK injuries contributing to record NHS waiting lists, increasing working days lost for businesses and pain and discomfort for individuals, it is clear that new solutions are needed to help people manage their own MSK health more effectively.
The NHS Long Term plan³⁴ committed to five practical changes, which included giving people more choice and control over their own health (personalised care) and more digitally-enabled care.
Clinically-led ‘physio-supported self-management’ provides a convenient, engaging, safe and effective way for people to put their MSK health in their own hands. By increasing clinician capacity, it reduces the burden on the NHS and, by encouraging early engagement and a prevention-first approach, it has the potential to reduce the number of working days lost by businesses as a result of MSK issues.
The results of this study show that the end-to-end physio-supported self-management provided by the Reach app is clinically safe and effective, achieves a high level of patient engagement and overcomes the problems of low commitment between appointments that often happens with in-person physio.
Key to the success of physio-supported self-management going forward will be the ability of healthcare providers to identify when to utilise it; providing the right treatment at the right time, to the right patient, through the right clinician.
It is for this reason that Ascenti has established Reach not as a standalone tool, but as part of its award-winning clinical ecosystem. Different patients will respond best to different treatment options and their preferences may change over time and depending on their progress. Similarly, some clinicians will prefer and excel in digital first roles, while others will prioritise a flexible hybrid career.
Ultimately, it is about greater choice; greater choice for patients, clinicians and partners. Physio-supported self-management will never replace in-clinic treatment, however, used effectively, as part of an end-to-end clinically-led system, it can improve the patient experience, augment clinician and patient outcomes, enhance professional standards and increase career opportunities, all while delivering clinically meaningful results. With the NHS burden so significant and the move towards personalised care already well underway, this report suggests that now is the time for physio-supported self-management to play a greater role in MSK treatment.
Ascenti is the leading independent provider of physiotherapy, mental health and selected clinical outsourcing services in the UK. They are a trusted partner to more than 20 NHS Clinical Commissioning Groups (CCGs) and more than 400 private businesses across the UK, serving NHS patients, pay as you go customers and private medical insurance members.
With extensive national coverage, Ascenti has over 300 highly trained physiotherapists and healthcare professionals delivering upwards of 600,000 treatment sessions annually. Enabling people to make headway after illness and injury, step back in to work after accidents, or simply stay active and keep moving forward in their daily lives.
Ascenti is a dynamic and progressive company – advancing physical and mental therapies by making them more accessible to all, raising standards and pioneering new digitally enabled services. To learn more, visit www.ascenti.co.uk.
Get in touch
To request a demo, or to find out more about how Ascenti Reach could benefit you and your customers, please email email@example.com.
10. https://bmjopensem.bmj.com/content/7/1/e000960 and https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254364